People’s experience of using this service and what we found
Risk management needed improvement to ensure peoples’ health and well-being was protected and promoted. We identified shortfalls in respect of the management of specific health problems. For example, management of weight loss, and diabetes. Staff had not had the necessary training to meet people’s individual needs including catheter care. Some aspects of medicine management needed to be improved to ensure people’s safety.
The governance of the service had not supported the service to consistently improve and sustain safe care delivery. Audit systems and processes, whilst in place, had failed to identify risks to people's safety and other aspects of the service that required improvement. There was a lack of clear and accurate records regarding some people's care and support. For example, diabetes and support with hydration. Communication handover sheets were not informative and not used effectively to inform staff. They were missing vital points for staff to follow up on, such as food and fluids to be encouraged, and people being unwell. Changes to people’s health and well- being were therefore not always planned for and monitored effectively.
We received positive feedback from relatives about the quality of care provided to people living at Mortain Place. Relatives told us they felt staff were kind and caring.
People received care and support from staff who had been appropriately recruited and trained to recognise signs of abuse or risk and understood what to do to safely support people. People were supported to take positive risks, to ensure they had as much choice and control of their lives as possible.
There were COVID-19 policies in place for visiting that was in line with government guidance. Families told us that they were welcomed into the home and followed the guidance currently in place.
Referrals were made appropriately to outside agencies when required. For example, GPs, community nurses and speech and language therapists (SALT). Notifications had been completed to inform CQC and other outside organisations when events occurred.
For more details, please see the full report which is on the CQC website at www.cqc.org.uk
Rating at last inspection and update
The last rating for this service was Good (published 03 August 2021).
Why we inspected
We received concerns in relation to staffing, risk management and care delivery. As a result, we undertook a focused inspection to review the key questions of safe and well-led only. For those key questions not inspected, we used the ratings awarded at the last inspection to calculate the overall rating.
We looked at infection prevention and control measures under the Safe key question. We look at this in all care home inspections even if no concerns or risks have been identified. This is to provide assurance that the service can respond to COVID-19 and other infection outbreaks effectively.
The overall rating for the service has changed from Good to Requires Improvement based on the findings of this inspection.
We have found evidence that the provider needs to make improvements. Please see safe and well led sections of this full report.
You can see what action we have asked the provider to take at the end of this full report.
You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Mortain Place Care Home on our website at www.cqc.org.uk.
Enforcement and Recommendations
We have identified breaches in relation to safe care and treatment and good governance.
Please see the action we have told the provider to take at the end of this report.
We will continue to monitor information we receive about the service, which will help inform when we next inspect.